Medicare Advantage

Updates from the CMS Innovation Center

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Before the Center for Medicare and Medicaid (CMS) Innovation Center was established in 2010, there weren’t many rigorous efforts in play to reduce costs and improve the quality of healthcare under Medicare. Since its inception, the CMS Innovation Center has focused on improving healthcare and cutting costs so that members enjoy greater benefits.

Much of the center’s work revolves around testing and refining models of care delivery. Doctors, patients, hospitals and other major stakeholders in the healthcare industry all collaborate to painstakingly design, rigorously test and carefully implement these models. Many of these models include financial incentives for prescribing prevention-focused and research-based care interventions. In other words, doctors and hospitals are reimbursed for providing care that delays the onset or prevents the development of serious disease processes.

Models developed by the CMS Innovation Center are just as carefully researched as the care you receive under them. In fact, each model must meet stringent selection criteria to be considered for innovation center testing. For an institution that’s been around for less than a decade, the innovation center has accomplished quite a bit. Its notable achievements include:

  • Launching over 30 new payment models in the past six years
  • Making more than 30 percent of fee-for-service payments contingent upon meeting quality and cost metrics
  • Spurring the development of electronic medical records and data analysis businesses
  • Supporting the creation of 38 state innovation models that have increased the quality of care, improved health and lowered costs
  • Stimulating the development of global payment arrangements in Vermont and Maryland
  • Saving 125,000 lives; avoiding 3 million infections and adverse events; and saving $28 billion through Partnership for Patients, a CMS Innovation Center initiative designed to improve patient safety

Perhaps one of the most practical achievements of the CMS Innovation Center has been to institute Advanced Alternate Payment Models. These programs tie financial incentives to early interventions for a variety of conditions. Doctors and other clinicians under the Quality Payment Program, an Advanced Alternate Payment Model developed to implement the 2015 Medicare Access and CHIP Reauthorization Act of 2015, get a 5 percent annual lump sum payment for prescribing early interventions for many diseases. This means that you can expect your doctor to take an increasingly proactive, prevention-based approach to your healthcare in an effort to delay or prevent the development of many chronic conditions.

Diabetes is one example of a high-cost, typically preventable condition. Since Medicare spent $42 billion funding diabetes care for beneficiaries aged 65 and older in 2016 alone, instituting the Medicare Diabetes Prevention Program Expanded Model by 2018 to pay for preventive diabetes services is a major priority.

The CMS Innovation Center is also slated to unveil three new payment models for patients who have had heart attacks, coronary artery bypass graft surgery and cardiac rehabilitation. These programs save costs and provide financial incentives for doctors and other clinicians to prescribe interventions that have been linked to improved health after heart attacks and other cardiovascular complications have already occurred.

The Comprehensive Care for Joint Replacement Model, which began in April 2016, will be expanding in a similar fashion. The Surgical Hip and Femur Fracture Treatment Model will assist clinicians in preventing further complications in patients who require additional care after a hip replacement. Again, the thinking is that it is still possible to restore function and vitality after you’ve gone through surgery or another type of intense medical even. Eligible patients can receive up to 90 days of rehabilitative care after hospital discharge.

Since your hospital is eligible to receive incentive payments for performance and improvement, you can expect lots of encouragement to participate in physical therapy and other research-based programs designed to support your healing. They will also diligently make sure you wear non-skid footwear, use bed and chair alarms, and practice other precautions against falling when you return home.

As home and community can be particularly influential to public health, CMS Innovation Center will be unveiling an Accountable Health Communities Model that provides social support towards achieving health goals in select communities. This model will help in determining if increased awareness of and access to social services specifically designed to impact healthcare can reduce costs, improve health and increase the quality of care that beneficiaries receive.

As is the case with all CMS Innovation Center models, data will be collected and made publicly available. Ideally, this will add to the center’s growing database of meaningful and measurable improvements in the quality of healthcare. The goal is to spur clinicians to provide lower-cost, research-based interventions aimed at prevention.